Study Guides test 1 Flashcards
This palpation to text service characteristic in a custom the person to be touched
Light palpation
Use relaxation techniques such as imaginary or deep breathing, altering pressure is better than one long continuous palpation avoid any situation in which the palpation could be causing internal injury or pain
Deep palpation
Requires the use of both of your hands to capture certain body parts such as organs kidneys uterus
Bimamual palpation
Part of stethoscope used for low frequency sounds
Traditional bell mode- press light on skin
Part of stethoscope for high frequency sounds
Traditional diaphragm mode - press firm on skin
Environmental conditions to consider for exam setting
Warm and comfortable, quiet, private, well lit
No distractions, noises, radio or television
Natural lighting is best
Position examination table so side of the person are easily accessible, The table should be at a height which you can stand without stooping and raise the persons head up 45°
Use a bedside stand for your equipment
Define the 4 physical examination skills?
inspection is concentrate and watching
Palpation confirms points that you noted during inspection Texter temperature and moisture swelling vibration pulsation rigidity lumps masses tenderness pain
Percussionist have been the person skin with short sharp stroke
Ask elation is listening to sounds produced by the body such as the heart and blood vessels in the lungs and abdomen
Part of hand beat for detecting vibration
ulnar surface of the hand
Where the stationary finger is struck when performing indirect percussion?
At the distal interphalangeal joint
Which assessment technique will you use first?
Inspection
How should the nurse assess abdomen by palpation ?
Start with light to detect surface characteristics and to accustom the client to being touched
When the examiner enters the room and the infant is sleeping , what to do first ?
Heart, lungs, abdomen infection
What’s the best description of the pitch of a sounds wave obtained by percussion
The number of vibrations per second
Factors that affect bp
Age Race Diurnal rhythm Weight Exercise Emotions Stress
Gait is as wide as what?
Shoulder width
Normal oral temp ranges from what?? but depends on?
96.4-99.1
Age
How to know the cuff is the right size for patient arm?
Make sure width is 40% of the arm
Best way to determine how far to inflate bp cuff ?
Palpate radial pulse while inflating , when non palpable add 30 above
Process of nociception
Transduction
Transmission
Perception
Modulation
The pain message is inhibited
Modulation
Signifies the conscious awareness of a painful sensation
Perception
The pain impulse moves from the level of the spinal cord to the brain
Transmission
Noxious stimulus In the form of Trumatic or chemical injury, burn, incision, or tumor it takes place in the periphery
Transduction
Pain but does not adhere to the typical and predictable phases. Often after injury heals
Neuropathic pain
Develops when functioning and intact nerve fibers in the periphery in CNS are stimulated which can be divided into four phases: trans duction, transmission, perception, modulation
Nociceptive pain
Most reliable indicator of pain ?
Subjective data- what the patient says
Facial pain scale for kids
Wong baker scale
At risk for if pain is not controlled
Atelectasis (collapses lung )
Increase heart o2 demand
Impaired wound healing
CRIES is an appropriate assessment tool for?
Preterm and neonates
assesses crying, oxygenation, vital signs, facial expression, and sleeplessness
Based on objective and observations
What are the cause with organic brain disorders?
Due to brain disease of known specific organic cause such as dementia or alcohol or drugs
What is the cause of mental disorders and how is it different than organic brain disorders
No organic origin has been established, anxiety disorder or Schizophrenia
Percent of Americans age 12 and up report being current alcohol drinkers?? And binge drinkers age 18-25 (5 drinks and up)
52% report drinking
40% are binge drinkers
What does AUDIT assesment do?
Helps to detect list of year and alcohol abuse such as consumption, drinking behavior, dependent, adverse consequences, and primary care setting
What does AUDIT c assessment do?
Heavy drinking and active alcohol abuse. Helps discriminate to be at risk from low risk and a cute critical care units
What does CAGE assessment do?
Test for lifetime alcohol abuse the primary care setting. Does not distinguish pass problem I’m active present problems. This is less effective with women
Effects of alcohol can cause what diseases or conditions?
Increases the risk of breast cancer
Liver cirrhosis
Hypertension and constricted blood vessels
Cardiomyopathy diabetes mellitus
What are the most common physical health problems that result from intimate partner violence
Blunt force injury or being struck by a hand
This can result in neurologic, gastrointestinal, gynecologic symptoms and chronic pain
What are the most common mental health problems that result from intimate partner violence
Depression, suicide, PTSD, substance abuse
What is the difference between abuse and neglect
Abuse can be psychological, emotional, sexual, or physical which can result in injury, pain, impairment, or Disease
Neglect is failure to provide basic needs and or services such as shoulder, healthcare, or medications
Which assessment shows the ability to lay down new memories?
Use of the four unrelated words test
A way to assess cognitive function and screen dementia ?
Mini cog
How to describe appearance of a client
example: Note posture, activity, dress, hygiene, cleanliness
Major characteristic of dementia
Impairment of short and long-term memory
With normal aging, it may take one longer to do something but what should not decline ?
General knowledge and abilities
What is a risk factor for intimate partner homicide (killing)
Abuse during pregnancy
What to routine give when evaluating a case of elder abuse
Baseline lab tests
Errors that may occur with 24 hour food recall
May not remember
Pt intake maybe abnormal from normal intake
Patient may lie for variety of reasons
Snack items and condiments maybe under reported
How can drugs interfere with nutrition?
Can affect digestion, Absorption, metabolism, or uptake
Purpose of a health hx ?
To provide a database of subjective information about the clients past and present health
At what age should the interviewer begin to question a child regarding presenting symptoms
7 years
What is personal space considered ?
11/2 to 4 feet
What not to use with aldolecents in interviews
Silence and reflection
Only use touch in interview when?
If interviewer knows the client well
10 traps of interviewing
Giving False assurance
Giving unwanted advice
Using authority
Avoidance language
Distancing
leading or biased questions
Professional jargon (how speak )
Talking too much
Interrupting
Asking why questions
